Longitudinal analysis of serum cytokine profile among patients with tubercular multifocal serpiginoid choroiditis: a pilot study

Long-Term Outcomes of Adalimumab Treatment in Conventional Treatment-Resistant Serpiginous Choroiditis

BACKGROUND/OBJECTIVES

To investigate the long-term efficacy and safety of adalimumab(ADA) in the treatment of patients with serpiginous choroiditis (SC) refractory to conventional therapy through quantitative parameters.

SUBJECTS/METHODS

A retrospective analysis was conducted on patients diagnosed with SC clinically and through fundus autofluorescence(FAF). Patients receiving ADA treatment were included. Demographic and clinical characteristics of the patients, association with tuberculosis (TB) infection, number of immunosuppressive therapies, recurrences, best corrected visual acuity (BCVA) change, and ADA-related side effects were recorded. The progression rate before and after ADA was calculated based on the area involved by FAF.

RESULTS

Sixteen eyes of 8 patients (3 female/5 male) were enrolled to the study. The median (IQR) age was 53.5 (16.5) years. Diagnosis was SC in 4, ampiginous choroiditis in 3, and TB-related serpiginous-like choroiditis in 1 patient. Peripapillary involvement was present in 10 of 16 eyes. The area involved by FAF continued to progress under ADA treatment, however the progression rate was decreased (p = 0.143).The BCVA was preserved (p = 0.772). The number of systemic and local treatments decreased with ADA (p = 0.025 and 0.019, respectively). Additionally, the number of recurrences was reduced with ADA (p = 0.002). Median (IQR) follow-up was 45(28.75) months. Two patients experienced ADA-related side effects (pulmonary TBand rash).

CONCLUSIONS

Our findings suggest a promising role for ADA in halting the progression of SC and have implications for improving outcomes. Despite the evidence in the literature at the level of case reports, ADA can be used effectively with close monitoring for potential risks.

Tubercular serpiginous choroiditis

Tubercular association with serpiginous choroiditis, also called ‘serpiginous-like choroiditis’ or ‘multifocal serpiginoid choroiditis’ (MSC) is reported from world over, especially from endemic countries. Though the exact mechanism is not yet clear, a direct or indirect infectious trigger by Mycobacterium tuberculosis (MTB) is believed to cause choroiditis.

The link of immune mechanisms with ocular inflammation caused by MTB is emerging, and has been supported by both experimental and human data. The molecular and histopathological findings of tubercular serpiginous-like choroiditis have been demonstrated in clinicopathological reports, as well as in animal models. Young to middle-aged healthy males are more frequently affected. The choroiditis lesions of tubercular serpiginous-like choroiditis evolve as multifocal lesions, affecting the retinal periphery as well as posterior pole. They begin as discrete lesions, and spread in a serpiginoid pattern to become confluent. Fundus imaging including autofluorescence is extremely helpful in monitoring patients for response to therapy. Its diagnosis is essentially clinical. Corroborative evidence is obtained by a positive tuberculin skin test, or a positive QuantiFERON-TB Gold (Cellestis, Carnegie, Victoria, Australia) test, and/or radiological (chest X-ray or chest CT scan) evidence of TB elsewhere in the body. Systemic corticosteroids are the mainstay of therapy to control active inflammation, while ATT helps to reduce recurrence of inflammatory attacks. Immunosuppressive agents are indicated in cases with relentless progression, paradoxical worsening, or recurrent choroiditis.

Automated lesion segmentation and quantification for prediction of paradoxical worsening in patients with tubercular serpiginous-like choroiditis

To develop and evaluate a fully automated pipeline that analyzes color fundus images in patients with tubercular serpiginous-like choroiditis (TB SLC) for prediction of paradoxical worsening (PW). In this retrospective study, patients with TB SLC with a follow-up of 9 months after initiation of anti-tubercular therapy were included. A fully automated custom-designed pipeline was developed which was initially tested using 12 baseline color fundus photographs for assessment of repeatability. After confirming reliability using Bland–Altman plots and intraclass correlation coefficient (ICC), the pipeline was deployed for all patients. The images were preprocessed to exclude the optic nerve from the fundus photo using a single-shot trainable WEKA segmentation algorithm. Two automatic thresholding algorithms were applied, and quantitative metrics were generated. These metrics were compared between PW + and PW- groups using non-parametric tests. A logistic regression model was used to predict probability of PW for assessing binary classification performance and receiver operator curves were generated to choose a sensitivity-optimized threshold. The study included 139 patients (139 eyes; 92 males and 47 females; mean age: 44.8 ± 11.3 years) with TB SLC. Pilot analysis of 12 images showed an excellent ICC for measuring the mean area, intensity, and integrated pixel intensity (all ICC > 0.89). The PW + group had significantly higher mean lesion area (p = 0.0152), mean pixel intensity (p = 0.0181), and integrated pixel intensity (p < 0.0001) compared to the PW- group. Using a sensitivity optimized threshold cut-off for mean pixel intensity, an area under the curve of 0.87 was achieved (sensitivity: 96.80% and specificity: 72.09%). Automated calculation of lesion metrics such as mean pixel intensity and segmented area in TB SLC is a novel approach with good repeatability in predicting PW during the follow-up.

Yellow Subretinal Lesions following Initiation of Antituberculosis Therapy in A Tubercular Choroidal Granuloma: A Sign of Paradoxical Worsening?

PURPOSE

To describe the presentation and management of atypical subretinal lesions following initiation of antitubercular therapy for a tubercular choroidal granuloma.

CASE REPORT

An 18-year-old female was diagnosed with choroidal granuloma and shallow exudative retinal detachment in the left eye. Biopsy from a cervical lymph node was positive for tuberculosis. She was treated with antitubercular therapy (ATT) and oral steroids. After one week of therapy exudative detachment increased markedly and discrete yellowish-white subretinal lesions appeared first in the inferior periphery, then temporally and later involved the macula leading to a drop in visual acuity. A diagnosis of paradoxical worsening was considered and she was managed with a higher dose of oral corticosteroids, intravitreal methotrexate and intravitreal ranibizumab. The granuloma healed and the subretinal lesions as well as exudative detachment gradually resolved with improvement in visual acuity.

CONCLUSION

Subretinal yellow-white lesions may develop as a paradoxical response to ATT.

Paradoxical reactions in ocular tuberculosis

Paradoxical reactions following initiation of anti-tubercular therapy have been documented most often in extrapulmonary tuberculosis. A combination of factors such as delayed hypersensitivity, decreased suppressor mechanisms, and an increased response to mycobacterial antigens mediated by the host’s immune system have been implicated in the development of these reactions. Similar worsening in patients with ocular tuberculosis while on treatment has been described. It is therefore important for the clinician to be aware of this occurrence, as prompt recognition and timely institution of corticosteroids and immunosuppressants can lead to restoration of vision. In these patients, an alteration or discontinuation of anti-tubercular therapy may not be indicated.